Another nightmare

Another mass shooting last weekend, this time in Las Vegas. Funnily enough, I had originally planned to go to Vegas this weekend. My bf had even asked for a day off from work so that we could spend a 3-day weekend together. But due to various circumstances, we elected not to go to Vegas after all. Thank goodness for that, as I don't think I would have been comfortable making the trip after the shooting outside Mandalay Bay. Having stayed at the Delano twice for SHM meetings, I was very familiar with the area around Mandalay Bay, including the venue where the shooting took place. And I couldn't help but wonder, what if something like this happened to me?

In my mind I saw myself lying in an ICU bed, on a ventilator, unresponsive to all stimuli, my head covered in bandages from a bullet to the head. Massive brain damage with no hope of recovery. I saw my parents at my side, then my sister and brother-in-law, and my boyfriend. Everyone is crying. My niece and nephew are too young to visit an ICU and I would not want them to see me like that anyway. I see my mother wailing, the way she cried when my maternal grandparents died. I see my father trying to keep his emotions in check, but even he cannot stop the tears from flowing down his cheeks. I see a representative from TOSA standing outside my room, preparing to talk to my family about organ donation. I had listed myself as an organ donor on my driver's license, and I have spoken to my parents about how I would want to be an organ donor if I died. I'd like to think that they would honor my wishes. In my mind I can also see my loved ones saying goodbye to me for the last time, but the mental image of this has brought me to tears myself.

This is not a far stretch of the imagination. Ever since our hospital became a trauma center, I've seen firsthand what humans can do to each other. A man who murdered his girlfriend in a nearby town became our patient when he turned the gun on himself and shot himself in the head. He did not survive, but before he died, TOSA was able to ensure that his organs would be harvested  and donated to others in need. I wonder who granted permission to harvest his organs. Did his parents agree to it as a way of making up for the life that their son took away? Who knows.

All I know is that I never want my family to experience the scenario I outlined above. We should not have to live in fear that violence will take our lives away, but lately this seems to be more likely a reality. And that's very sad.

Not taking life for granted

A lot of craziness happened this weekend. First a young singer from "The Voice" got shot to death, and now the mass shooting at a club in Orlando where 50+ people died. It just goes to show that no matter where you live in the world, no place is truly safe.

I learned early on that life can be cut short at any time. In my med school class alone, one classmate was killed by her husband, another died of cancer, and yet another is fighting cancer now, diagnosed with lymphoma around the same time she gave birth to her first child.  Hopefully she will do well with her treatments. And the patients I see, some go from healthy to dead within days, or even weeks. One memorable patient was an elderly dentist who came to the hospital because people told him he looked "yellow." He was diagnosed with pancreatic cancer, and less than 2 days later, he was dead after he developed a GI bleed and aspirated. It was extremely quick, and if there was any consolation to his family, it was that he didn't have to go through the prolonged pain and suffering that most patients do. He was healthy for all but 2 days of his life. Not a bad way to live and die. 

Then there are the dreams. I rarely remember my dreams after waking up, but there have been a few times in life where I'll be struck by a sense of deja vu and think, "I feel like I've been through this before." But I do remember my dreams about death, only because they were so vivid and disconcerting. There was one dream where I'm lying in bed dictating my will, and another where I'm looking down at my body, and I don't recognize myself because I'm so thin and emaciated from cancer. The latter dream left me shaken after I woke up, and it still scares me to think about it.

This is why I try to live in the moment. Why I have no trouble spoiling myself after a long day at work, or splurging on a new pair of shoes that I really don't need, or traveling long distances to visit my family and friends. I don't want to have too many regrets when I die, and when I die, I want to feel like I'd lived a life well lived.

Blast from the past

A few days ago, I had a near-encounter with my childhood bully.

When I was around 7-9 years old, I got picked on a lot in [language] school because I was one of the youngest kids in my class, and I was an easy target for my classmates. The ringleader was a guy about 2 years older than me and his father was the principal, so he probably got away with a lot of stuff. I won't go into detail what happened back then, but it usually ended up with me in tears (I cried easily as a kid). It was a miserable time of my life, and to this day I tend to avoid anything related to that particular church (and maybe church in general) because it was not a safe place for me at a time when I needed (and did not get) extra support.

We grew up, and while the bully and I still had mutual friends (and the same music teacher), we never really crossed paths again after junior high. One of my friends developed a crush on him at a region meet; I was quick to talk her out of it. I'd heard he'd gone out of state for college, but in my 4th year of undergrad, I ran into his mother on a plane on the way home from a med school interview. She then proceeded to tell me how her son was attending a prestigious medical school and was doing very well for himself, emphasizing his interest in research (which I personally did not care for). When I told her which medical school I got accepted to, she immediately cut me down, saying it was a horrible school and that I should withdraw my acceptance. Wow, really?

Flash forward nine years to 2014. My medical education complete, I was starting my 3rd year as a hospitalist when I learned that the bully had also begun practicing medicine in the same city as me.  My PCP belongs to a multispecialty clinic which sends regular email updates on any new hires; imagine my surprise when I opened an email which announced that the bully was joining the clinic as a medicine subspecialist! "You've got to be kidding!" I muttered out loud. Several other doctors in the vicinity asked what had happened. Not wanting to go into detail, I just said that one of my least favorite people will be practicing medicine across town. Some of the male docs immediately assumed that the bully was an ex-boyfriend; that's a laughable idea.

At that time, I wondered what would happen if I did run into the bully again. Would he even remember who I was? Was he ever sorry? Does it even matter, 20+ years later? We're all adults now, and people change. I can definitely say I'm no longer the crybaby that got picked on almost every week; in fact, people tell me that as far as first impressions go, I can be pretty cold until I warm up to you. Interestingly, not long after I saw that email, I had a dream in which the bully and I talked things over (don't recall exactly what), and at the end he said he was sorry. After that, I decided that I would no longer let him cast a shadow over me. Though we may live in the same city, the chances of us crossing paths was very low, and I put him out of my mind.

Then, while visiting my family over Thanksgiving, I recognized the bully's father when we went to one of our favorite restaurants for lunch. My dad recognized him, too, and while those two stopped to exchange greetings, I proceeded to my table without saying hello. I wondered if the bully was there, too, and suddenly I dreaded the thought of having to come face to face with him. Was that my inner child rearing her head? My dad returned to the table and told me that he saw and shook hands with the bully, and said that I should be polite and say hello, too.

I did say hello to his father, but when I saw anyone who even looked remotely like the bully in the buffet line, I turned my head and made myself invisible. Because even though it's been 20+ years, I had no desire to acknowledge his presence or speak to him. "Hate" is too strong a word as I do not waste time thinking about him and he is not worthy of whatever hatred I may possess; however, I think I can certainly say I dislike him for how his bullying affected me in the long run. Maybe I was a coward for avoiding him, but he has no place in my life, and I prefer to keep it that way.

Of course, there's still a slim chance that I'll cross paths with him again. And if it happens, I hope I'll be able to leave childhood hurts aside, and show that I've truly changed for the better.

Dangerous Skies

I used to never be afraid of flying but with all the recent airline disasters in the past year (most recently the recent deliberate crash of Germanwings 9525 into the French Alps), I can't help feel a bit anxious every time I set foot on a plane now. The latest reports suggest that the co-pilot of the Germanwings flight had a medical condition (depression?) that deemed him unfit to fly, yet his employers knew nothing about it. If his condition was really that serious, did his physician have a duty to report this if working meant putting other people's lives at risk?

I had a similar case approximately 2 years ago when I admitted an airline pilot to the hospital after he had a seizure during a marathon. His CT head was negative and he later got an MRI, but he left AMA before the results came back. He'd believed that dehydration was the cause of his seizure (he did have AKI but felt better after getting fluids) and saw no need to stay in the hospital. Usually when people leave AMA we don't follow up on their results, but the following day I looked up his MRI report and saw that he had a brain mass. I asked my partners what to do, and they said to call him and his PCP so that he could self-report to his employers that he could not work.

I called the patient at home and gave him his MRI results, telling him that he needed to schedule an appointment with his PCP so that he could arrange followup with a neurosurgeon. I further told him that he could not fly anymore and needed to tell his employers so. Then I faxed a letter to his PCP explaining what had happened, then called the PCP the next day to confirm that he'd gotten the letter.I was somewhat amused when the CMO of our hospital called me about a day after I spoke with the patient's PCP telling me I needed to notify his employers immediately of his diagnosis so that he can't fly. "Already done," I told him, and couldn't help but feel satisfied that I was one step ahead of him.

Within a month of diagnosis, the pt had his brain mass resected and was diagnosed with stage IV GBM. What happened afterwards I don't know, only that the craniotomy left him debilitated and he required extensive PT and OT before he could undergo XRT. I doubt he will ever pilot a plane again, but at least we were able to stop him before he potentially had a seizure mid-flight, and no lives had to be put at risk. Who can say what was going on in Andreas Lubitz's mind when he chose to fly the plane into the Alps. Committing suicide is selfish enough, but why take 149 other lives with you? Nothing about this case makes sense to me. I shouldn't have to wonder if my pilot is of sound mind and body before I board a flight; that should be a given.

Hospital Under Siege

Yesterday a cardiothoracic surgeon at Brigham and Women's was shot in cold blood on a routine day at work by the son of a patient whom he'd treated. We don't know the whole story yet; apparently there were complications and the patient (the shooter's mother) had died. No one likes to think that this could happen at their hospital, and yet it did happen, and at one of the nation's most prestigious hospitals no less. Needless to say it's shaken me (and several coworkers) to the core.

The concept of doctors getting attacked at hospitals is not a new one. I still remember the episode of ER where a schizophrenic patient stabbed two doctors, one of whom died and the other ended up addicted to narcotics. Then there was that episode of Grey's Anatomy where the disgruntled husband of a patient who'd died went on a shooting spree at the hospital in revenge. He, too, was targeting doctors, specifically the doctors involved in the care of his wife, and killed many people.  I remember watching that episode while on call in residency, and my classmates and I briefly discussed where the best places to hide were in our hospital. And yet when an earthquake struck the East Coast and the very room where we were relaxing began to shake, none of us knew what to do. We just sat where we were watching the closet door sway back and forth, wondering whether to evacuate or wait it out.

It did cross my mind once or twice to wonder where the safest place in the hospital would be if there were a shooter in the hospital. To reach another floor, you'd have to use the staircases; you need a hospital badge to get from floor to floor and if the shooter did try to enter a staircase, he's essentially trapped there without a badge. The physician's call room is code protected, but that's not safe either. Some of the nurses know the code and could be forced to give it up under duress. Not to mention once you're in there, there's no escape. The shooter could just shoot through the glass even if I did hide under the table or behind the couch. Then of course there's the random empty patient's room, but no matter how much I think about it, there really isn't a safe place in the hospital.

Then the next question: flee or fight? I'll be the first to say I'm a coward when it comes to confrontations, that when I see a ball flying toward me I'd duck before I'd try to catch the ball in mid air. And yet, I'd like to think that if it really came down to it, I'd fight back if I had to. It's not like I have zero training in self defense. I've been taking kickboxing classes for over a year; I know my kicks are more powerful than my punches, I know where to press my thumb into someone's throat to cut off their airway, and I know where to aim to bring someone to their knees. But what good is that against a gun, which could snuff out my life in an instant, as it did the life of Dr. Mike Davidson?

It's sobering to think that any one of us, if we pissed off a patient too much, could end up dead, injured or worse. I have no intention of letting fear take over my life, but I will be vigilant just in case.

Influenza

I cannot believe how insanely busy things have been since December. The influenza (and especially H1N1) epidemic has been horrible. I got my first H1N1 patient in early December, a 40-year-old woman with no history aside from smoking 2 packs of cigarettes a day who came in with full-blown ARDS and hypoxia.  She said both she and her husband had flu symptoms, but while he recovered, she did not, and ended up being hospitalized at a small country hospital for presumed pneumonia that did not respond to antibiotics. She got transferred to our hospital when it was clear she wasn't getting better. When I presented her to the pulmonologist, describing her symptoms (high fever, shortness of breath, some hemoptysis), he shook his head and said, "That's classic (for H1N1)." When I asked my patient if she would consent to being intubated, she gave me the thumbs-up, then proceeded to spend the next 10+ days on a ventilator. Fortunately, she was one of the lucky ones, and she was able to go home on Christmas Eve.

Another of my patients, a 68 year old man who was still climbing on roofs working as a carpenter, came to the hospital c/o a 1 week history of cough, fever, sore throat and generalized aches. Because he only had hyperlipidemia, we initially treated him for community acquired pneumonia. The next day, I walked into his room and said, "Hello, Mr. ___, how are you doing---whoa!" The reason for the exclamation? There was a LARGE hunk of bloody mucus sitting in a basin that he'd been spitting into. With my other H1N1 patient fresh on my mind, I called pulm immediately. Sure enough, he had H1N1, and he ended up on a Rotaprone bed for at least a week. Eventually, however, he recovered, though he's now so debilitated, both physically and mentally, that he got discharged to a nursing home after a 1 month hospitalization. Of course, it could have been worse. He could have died.

Fever. Cough. Hypoxia. Hemoptysis. "Fluffy" chest X-ray. Anytime I see 3 or more of these characteristics in the same patient, I immediately think H1N1 until proven otherwise. And even then, sometimes the H1N1 PCR is negative. Doesn't matter; if it acts like H1N1, we treat it like H1N1. I had two patients who tested negative for H1N1 but had the classic presentation. Both were spared intubation, fortunately; one guy recovered enough to go home after a week, while another remains in the hospital 3 weeks later on high F1O2. It's amazing how the same virus affects different people in different ways. When I walked through the ICU, I was struck by how young some of the intubated patients were. One thing they had in common: they didn't get their flu shot this year.

In our hospital, most of our sickest patients were women in their 30s-60s, often overweight, diabetic, or worse, pregnant. We've had 3 pregnant H1N1 patients come through our ICU. The first was a 30-year-old who denied being pregnant on 2 separate occasions; only after she was intubated did her family inform us that she was, in fact, pregnant. A stat ultrasound showed she was 31 weeks along, and because she was so unstable (and on a Rotaprone to boot), her ICU room was turned into a makeshift OR and she had an emergency C-section. Her baby survived, though she did not; she was transferred to another hospital on ECMO several days later and ended up dying. The second pregnant patient was only about 25 weeks along; they put her on ECMO and got to the other hospital, don't know how she did. The third, a woman in her 40s and 25 weeks pregnant with her 5th child, initially got admitted for DKA but almost immediately became septic while in the ED. The baby was delivered via emergent C-section but did not survive. The patient lasted about 3-4 days maxed on 5 pressors before she, too, succumbed. The last case in particular was very tragic, as the H1N1 hit that poor woman hard and fast, and her family lost both her and her child.

The news recently something along the lines of how 9 people so far have died of the flu in our city alone this year; I think the number is probably much greater. Even the pulmonologists said that this winter has been the worst H1N1 they'd seen, even worse than 2009. As a result, our hospital beds are almost always full, there's almost never room in the ICU and IMC because so many people are on the vent, and the doctors are overworked and overwhelmed. Me included.

One of these days, I got to start taking care of me. Otherwise, I don't know how long I can keep doing this.

Judgment and Faith in Medicine

 One of the challenges of being a physician is making decisions with regards to a patient's care and well being. The decisions we make are oftentimes derived from both our training and the lessons we learn in residency and in the workplace. And sometimes the choices we make are not easy.
Two nights ago I was asked to admit a patient who had a syncopal episode in front of his daughter, got intubated at an outside hospital, and then transferred to my hospital for stroke workup and management. By the time he arrived at the ER and I got to see him, he was wide awake, following commands, and able to respond to simple questions by nodding or shaking his head. His chest X-ray was clear, and his ABG looked great. He looked like someone who could be extubated on the spot, and his RN agreed he looked like he could "fly," the term we use for patients who do well post extubation. The question: since the patient was in the ER, who makes the call regarding extubation?

I initially spoke with the ER doc who admitted him, saying that he was awake and alert (which he was NOT when she saw him), and suggested that he could be extubated. Unfortunately for me she was dealing with an acute CVA at the same time, and after speaking briefly to my patient's family, she said that because she didn't know why he became unresponsive (drugs, MI, CVA, etc), she was not comfortable extubating him in the ED. As far as she was concerned, he would remain intubated until he got to the ICU, where she wouldn't have to deal with him anymore.

I saw things differently. Whenever I did MICU rotations in residency, one of our attendings always ran through a checklist on each patient to see whether or not the patient still needed to be in the MICU (if not, call them out) or, if they were intubated, whether they could be extubated. My patient was awake and alert, and his chest X-ray was normal. I didn't know why he passed out, but I thought that most likely he was intubated prematurely. I was nervous, too, about extubating him in the ER with the possibility that he would crump shortly afterwards, but no matter what I couldn't justify sending this man to the ICU on a ventilator to spend the night in a propofol-induced sleep , then consulting pulm-crit in the morning just to extubate him. In the end, I had to go on faith, and believe that this man would do well. Taking a deep breath, I wrote the order for RT to extubate him.

I stayed in the ER and kept a close eye on the patient as RT extubated him, and his SpO2 was 97% on room air! He was placed on nasal cannula and was able to answer a few questions for me, saying that the last thing he remembered was talking to his daughter. He was able to move all four extremities, and the house supervisor asked, "You still want him in the ICU?" Not anymore. He was admitted to our IMC instead, which was good b/c there were only 2 ICU beds left in the entire hospital. In fact, I later learned that he was discharged home today.

So what did I get from all this? I had thought that the ER doc was too "chicken" to make a call regarding extubation, but now that I think about it, this was uncharted territory for her, too. Not many people come to our emergency room already intubated only to be extubated while IN the emergency room. In fact, I don't know how many of my partners would have made the call to extubate in the emergency department. Was I being too daring for my own good? I reviewed the case with a pulm-crit attending, and he assured me I'd made the right call. Thank goodness. I just hope I continue to make the right decisions throughout my career.

Patient Confidentiality

Back when I was in residency, I had an HIV positive patient whose wife was unaware of his HIV status (apparently he didn't find out until AFTER they got married), and he refused to let anyone tell her. He'd tell his doctors that he was going to, but then never would. He would never want to answer any of our questions as long as his wife was in the room, even if it was for something non-HIV related, like how his chest pain was doing. To be fair, he took his HAART faithfully and his viral load was undetectable, but even as an intern the hypocrisy of the situation was not lost on me. He was one of the patients that no attending in the hospital wanted to accept just because he was an ass (that must be true only of teaching hospitals because in the real world we usually aren't supposed to refuse patients), and I wonder if his wife ever found out.

I'm now caring for another HIV patient whose parents don't know about his status. He'd developed a bad case of PCP, but before intubation he made it clear that his parents were not to know that he had HIV. I've seen his father fervently praying over him and wonder what sin he committed to acquire AIDS (most likely premarital sex with an infected male/female, given his age), and wonder how unforgiveable that truly would be to his parents.  I don't know what to say when his parents ask why he's not getting better and why his pneumonia just isn't going away. Can't exactly say, "Well, Mr. ___, your son doesn't really have much of an immune system because his CD4 count is one of the lowest I've ever seen in my career." Can't be judgmental when the guy's so sick, but I wonder what the end point is. If he should die, do I let his diagnosis go with him to the grave? The Tarasoff ruling allows us to break the shackles of confidentiality when there is intended harm towards another, but what am I supposed to say if this guy ends up dying and his mother asks why? The things we deal every day...

Fullmetal in the hospital

A few days ago while I was working in the ER, I was borrowing a nurse's computer to print out a patient's vitals when I spotted the name "Edward Elric" on the list of patients in that part of the ER. Almost immediately I burst out laughing. For anyone not familiar with anime, Edward Elric is the main character of a well known anime series called Fullmetal Alchemist. I've never seen FMA myself, but I've been to enough conventions to recognize the characters, not to mention I've seen Ed's voice actor Vic Mignogna at multiple cons and he's made no secret of the fact that Ed was one of his favorite characters to ever voice. I know the basic plot of the story, how Ed and his brother Al used alchemy to attempt to resurrect their dead mother, and in the process Ed lost an arm and leg and Al's soul got trapped in a suit of armor. I also know that there are a lot of themes in the series, i.e. the bond between brothers and how dangerous it is to play God with other's lives. One of these days I'll have to watch FMA, but for now, all that mattered was that there was someone calling himself Edward Elric in the ER, and apparently I was the only one who knew that name was a fake.

I saw "hallucinations" as the chief complaint, so it was entirely possible that this guy was psychotic and really did believe himself to be Edward Elric. However, he wasn't my patient and I wasn't about to violate any HIPAA laws by reading up on his file. So I did the next best thing and snagged one of the ER docs, telling him that the name "Edward Elric" was a fake one and that the ER social worker was going to have to try harder to learn his real identity. I even pulled up Ed's picture on my phone and showed it to him to prove that I wasn't crazy either. The ER doc laughed, saying that his patient didn't resemble Ed at all. He was also amused that it was thanks to my "inner nerd" that all this came to light. What can I say, it's not everyday that anime and medicine come together in my workplace. I later texted Kyle, a voice actor I befriended who'd also worked on FMA, to say that "Edward Elric" showed up in in the hospital (without going into too much detail); he thought that was pretty funny.

"Edward" was in the ER for at least 3 days waiting for a bed at a psych hospital, though by the second day, some of the ER docs had looked up FMA to learn about the real Edward Elric. "I heard you're the one who found out it wasn't his real name," said another doc. And apparently the ER docs were still talking about it over the weekend (I got those 2 days off) and my partners heard about it, too. I'm guessing he finally made it to a psych hospital; hopefully he'll get the help he needs and not fall into more delusions of grandeur.

Studer Training

Several months ago, my colleagues and I attended a mandatory meeting with a coach from the Studer Group, a group of physicians that educates other physicians about how to improve patient satisfaction and outcomes. It was four hours of teaching us how to demonstrate empathy toward our patients, ways of going "above and beyond" i.e. sitting down when talking to a patient, touching the patients, communicating, etc. Most of my colleagues thought it was a bunch of baloney; as for me, this was nothing that our med school hadn't already emphasized back in the day. I do try to sit down with my patients whenever I get the chance, I listen to their concerns, and I'm not afraid to lay a hand on their shoulder when they're crying. This I attribute to my med school training, not to the Studer Group.

Imagine my surprise (and dismay) today when the chief medical officer of the hospital poked his head into the physician's dictation room where I was writing my notes and asked if I had time to spare for him and a Studer coach (the same coach from above) to shadow me while I talk to my patients. I haven't had anyone shadow me since I was a med student, and I was sorry to say I couldn't recall much from the Studer training session. The CMO, Studer coach, and I saw 4 patients together: an osteomyelitis case, a chest pain, an A-flutter s/p ablation, and a new ESRD pt. I chose these patients b/c they were pretty straightforward and I had a pretty good relationship with them so the coach could see me at my best. The coach seemed pretty interested in where I trained, and asked where I thought my strengths were. I told him that I take time to listen to my patients, and that I make an effort to develop a relationship or rapport with them while they are under my care. I even gave some props to TCOM by saying our old motto, "Treat the patient, not the disease."

As for criticism, the coach said that I never once sat down while talking to my patients (the other chair was occupied and I didn't want to sit on the patients' beds), and he also commented that I rarely ever smiled. That's nothing new; I know my default facial expression is more of a frown than a smile. Still, I could see his point. One of the nephrologists at our hospital is extremely bubbly and friendly, and just seeing her makes me want to smile. Now I wonder what kind of disservice I've been giving my patients by not smiling when I walk through their door. And as for sitting down to talk to patients, they say sitting down gives patients the impression that our face-to-face time lasts longer than if we spoke with them while standing. That, thankfully, was one tidbit I remembered from the Studer training session, and the coach seemed pleased when I was able to recall it. Overall, he said I was doing pretty well, and that with a bit of tweaking, I can do even better.

Some of my partners wanted to hide when they heard that the Studer coach and CMO were walking around finding people to shadow, but I think everyone's going to get it eventually.

When the homeless can't help themselves

I don't think there's a single doctor in the US who has not had to care for the homeless population. A lot of them have multiple medical comorbidities and can't afford to take care of themselves properly on the street, or else spent whatever money they earn on drugs and alcohol. A lot of these people are regulars in our hospital. There's a 23 year old meth user with ESRD (due to malignant HTN) who never goes to dialysis and instead shows up at the hospital whenever his scrotum swells up (I wish I were joking about this chief complaint) or pruritis. He's so noncompliant that many nephrologists in the city want nothing to do with him; the ED docs don't even admit him every time he shows up anymore. Usually they check his labs and only admit him if his lytes require him to get dialyzed. Then there's a 21 year old type I diabetic who can't afford insulin (another meth user) and comes to the hospital at least once a month (on average) for DKA. When I was a new attending, I felt sorry for him and donated $5 so he could afford his insulin at Walmart. It didn't solve anything; he returned to the hospital the following month. I felt like a fool afterwards; he probably spent that money on meth.

Most recently I took care of a homeless guy with cellulitis who required an I&D of his foot. He was supposed to have gone home the day before, but had refused b/c he was homeless and was not able to receive wound care at the homeless shelter. More importantly (and irritatingly, to me), he said that if he was discharged from the hospital, then he was going to go straight to the nearby county hospital because in his own words, he did not feel safe walking and was afraid he would fall and hurt himself. Never mind that I saw him walking pretty well in his room and pulling his IV pole beside him to boot. I usually feel sorry for the homeless patients I care for, but he definitely wasn't even trying to make me sympathize with him. He was Spanish speaking only so I had the tech in the room to help me translate, and not once did he look directly at me; in addition, I didn't need to understand Spanish to know that he was being a total jerk. I asked if he could stay with his son, and he said no, b/c his ex-wife lives with his son. What was I supposed to do? Discharge him and have him run "crying" to the county hospital that foot hurts when he doesn't even need to be in a hospital anymore? That would certainly look bad for me and my hospital. I went and talked to our social worker about the situation, and she said that since he had Medicare/Medicaid, she'd try to get him into a SNF. "Do you think he'll agree to it?" she asked. Of course he would, if it meant he'd get fed three times a day and wouldn't be stuck outside in 100 degree weather.

Not surprisingly, the patient agreed to a SNF, and further requested (or demanded, who knows) that he go to a SNF where the staff spoke Spanish. If not for the fact that our hospital is big on patient satisfaction (they call patients 2-3 days after discharge for feedback on their stay), I don't see why he should be allowed to choose which SNF to go to. Fortunately there was such a SNF and he was discharged later that same day, but seriously...it doesn't take too much nowadays to become disillusioned with healthcare today.

The night from hell

I've been working nights for the past 4 days, and during my 2nd night, the ED was full of drunks and psych patients. One ED doc grumbled that he was tired of people calling him a "f***head;" a lot of people joked that maybe the supermoon was the reason why the ED was so full. Fortunately for me, drunks and psych patients don't need to be admitted unless they're medically unstable, so I only did 5 admissions that night. Even still, I had the feeling that I would pay for it much later.

Last night was my worst night call to date. I got 4 patients in the first 30 minutes, already a bad start, but I was able to triage them and see them in order of sickest to least sick. However, the admits kept coming, and after 3 hours I had 9 admits and was still at least four in the hole. The ED doc even asked to make sure I didn't have any sharp/hard objects in my hand before he gave me another admission. I was hoping there would be a time where I'd be able to catch up on my admissions and not be 2+ in the hole, but it never happened. I was in the hole all night, and as the admits kept coming, I'm sorry to say that I also became angrier and angrier. Usually I'm good at keeping my emotions at bay, but not last night. I was slamming charts on the table, dropping f-bombs when talking to the ED docs as they gave me yet another admission, and slightly rude to the floor RNs who called to say their patient needed a sleeping pill. By the end of my shift, they'd given me 16 admissions, of which I could only complete 15 because I didn't have time to see the 16th. I didn't finish dictating my h&p's until nearly 7 a.m., a whole hour after my shift ended. If I'd seen that 16th patient, who knew when I would have left the hospital. At any rate I was in a completely bitchy mood as I left the hospital, which I'm sure did not go unnoticed by my coworkers.

Went home, slept for 4-5 hours, then treated myself to a 60 minute massage (found a 20% off coupon in my inbox, decided to use it). There were a lot of knots in my lower back and neck (no surprises there; I've been waking up stiff for the past few days), but those got smoothed out by the therapist. It was just what I needed after 4 days of working nights; I feel better now =)

Prisoners

I recently had a patient get admitted for a-fib, and I learned that he'd been in a correctional facility (aka prison) for the past five years. I don't know what he did to earn such a sentence (and who knows how many years he has left), but he was one of the nicest patients I'd ever had the pleasure of caring for. A few nurses and I wondered what crime he had committed in the past that landed him in prison, and in a way, I don't want to know. I'd rather keep the memory of him telling me, "God bless you" when I told him he could go home, rather than learning that he did something heinous like assault another person or commit murder. That reminded me of another patient I admitted one night, and the "what-if's" still haunt me once in a while.

Last month when I was working nights, I admitted a 29-year old male with asthma exacerbation. He said that he had become short of breath while walking on the street; I remembered he was pleasant to talk to. The following night  I heard a "Code Purple" (code for "Aggressive patient or family member") overhead pointing to his room, and I wondered what could possibly be going on because I remembered him being a nice guy and unlikely to cause trouble. Usually I stay away from Code Purples; security usually deals with all that, and I didn't think much of it later. I found out later that he had gotten into an argument with his ex-wife who had come to visit him.

Later on, I looked the patient up to see how he fared after he was admitted. Then I got a huge surprise: the patient's mother had called the hospital saying that he had told her that he had knives in his room and that he was going to hurt himself and some of the nurses who kept coming into his room and "bothering" him. In fact, he had used a fake ID to get into the hospital; in reality, he was wanted by the police for assault (apparently tried to choke his ex-wife prior to coming to the hospital) and has a strong history of violence. He'd had a bag in the room with him that he'd refused to let the nurses handle; when security searched him at the social worker's insistence, they found a machete and another knife in the bag. He then began making threats and ranting that there was a hitman out to get him. The police was then called to take him to jail.

I was speaking to one of the nurses about this today, and she commented that she and another nurse had "been chatting with him" most of that day, and no one knew that he had a knife in his bag. What if he'd chosen to act on his paranoia? What if he pulled out that machete in the ER while my back was turned and sliced off my head? What if he stabbed the nurses instead and then proceeded to attack other people in the hospital? I imagine something like that would have made national news and brought up the issue of safety in hospitals. How the hell did the patient get a MACHETE into the hospital? I know we don't have metal detectors, but usually personal belongings are well documented prior to the patient leaving the ER. I hate to think about what could have happened if the patient's mother didn't call the hospital, what kind of terror he could have unleashed if he became any more unstable in the mind. We were very lucky.

Not Enough Time/Grass Aspiration

Four days ago I got a new patient, a 58 year old alcoholic who presented to the ED complaining of worsening abdominal swelling, spontaneous bruising, and low urine output. On admission his creatinine was 7.7, BUN > 110, INR 3.3, and bilirubin of 13. He had full blown hepatorenal syndrome (HRS); in the words of the gastroenterologist, he was "sick as $hit." The nephrologist and gastroenterologist both did not think he was a candidate for dialysis due to the extent of his liver failure, which meant he would not survive this hospitalization.

When I asked the patient if he understood how he sick he was, he stated matter-of-factly, "I'm going to die." I spoke to him about hospice, and he asked if I would write the important points down because "I know I'll probably forget soon." Even then, as the ammonia built up in his system, he knew that there would come a time where he would not be able to make decisions for himself, and he told us who he wanted us to contact (a female friend who was caring for his cat) if something happened. He had two brothers, but they were estranged due to his alcoholism and poor life choices. He told me he wanted to go home to get his affairs in order and take care of his cat, and I said I'd ask the hospice people to come speak to him about it later that afternoon.

The hospice people never showed, and when I saw him the next morning (yesterday), he was a completely different person. He had become completely encephalopathic, moaning and restless, unaware of anything around him, no longer in any position to make any decisions for himself. His friend was at his bedside and very tearful, but she took solace in the fact that he had listed her as his go-to person, which spoke of his trust in her. She wanted to make him DNR (rightfully so), which the nephrologist and I both agreed with. The nephrologist estimated that he had less than 24 hours left to live, and she was right. He passed away at 3:00 a.m. this morning.

Later in the day I got a text from one of my partners regarding a new admission: "aspirated on grass." That's one chief complaint that I never heard of before. It was really an interesting story; my patient was on a riding lawn mower clearing brush in a park when a branch suddenly flew through the air and smacked him in the nose and mouth. He had not worn a face mask that day, and afterwards he had persistent cough, shortness of breath, and right chest tightness. His chest X-ray  was negative, but his CT chest showed that debris had completely occluded his right bronchus. The pulmonologist on call was out enjoying a bike ride when he got called to the hospital, but he got very excited when he saw the CT. It would definitely have made a great case study. We'll see how the patient does.

You again?!

Almost 5 years ago when I was doing my sub-I at Brack, I had this borderline, noncompliant diabetic patient who was a total jerk through and through. Although I'd forgotten his name, I remembered him well b/c my resident made me see him everyday. Back then he had kept coming back to the hospital with lower extremity cellulitis because he didn't take his antibiotics. I remembered how he kept refusing the MRI that we ordered for him to rule out osteomyelitis, how he threw things at the wall and cursed at nurses, how angry he was because we put him on a diabetic diet, and how his room reeked whenever we went into his room b/c he wouldn't bathe and sometimes wet the bed intentionally so that he could accuse the nurses of neglect. He was only 29 years old at the time, and I thought it was a shame that he wouldn't take care of himself.

During my rounds today, I spotted him in the hall talking to one of the nurses. He saw me, too, and at that point I was 90% sure it was him. How many young overweight guys with a BKA in a wheelchair are there in Austin? Then I heard his voice, and I was absolutely certain it was him. There was not a single day at Brack where he didn't find something to gripe about, and as he complained to the nurse about his doctor, I recognized his voice for sure. I later looked him up; it seems that in the years since I last saw him, he'd gotten an ostomy from an abdominal wall infection, and currently he wanted to fire his doctor for not giving him Dilaudid. Apparently the plan is to discharge him from the hospital tomorrow; hopefully he goes back to Brack because there's no way in hell I want to take care of him ever again. Hopefully he doesn't remember me; I'm sure he's seen lots of doctors and med students come and go since he probably goes hospital shopping. Sad that some people never change.

Discrimination among doctors

The other day I mentioned to one of my colleagues that a UT student recently emailed me asking me for advice on getting into medical school when her GPA (which she did not reveal) was "not very high." His response: "Apply to DO schools?"

I could not believe he said that, but then again, I don't think he knew I was a DO. Unless we ask each other or volunteer the information, I have no idea where my colleagues went to medical school or residency. And unless someone really looks at my ID or white coat, no one knows I'm a DO and not an MD. In the past 3-4 years I've been a doctor, I've never encountered any discrimination against DOs (or maybe I was just lucky). The hospital where I did my residency was a melting pot of US grads, DOs, and foreign grads; there were about 8 DOs in my class, and some of our attendings were DOs as well. There was no discrimination. We didn't care where we'd trained or what initials were after our names; we were colleagues first and foremost. I think there was one time I asked a friend why he went to med school in the Caribbean. His response:  "I can't believe you're even asking me that." Which is true. Why did it matter? At any rate, he's doing an endocrinology fellowship, and my other friends who went to Caribbean schools are currently doing fellowships in nephrology, cardiology, and ID. As for other DOs in my class, they matched into fellowships in cards, heme/onc, nephrology, and GI. Actually I think I'm the only DO who didn't match fellowship in my year, but that doesn't make me more of a failure. I'm making a very good living right now, and I'm well liked and well respected in my hospital by doctors, nurses, and patients alike. To me, that is success.

Later I mentioned the other guy's comment to one of my partners (about 20 years older than me), thinking he'd be a more supportive since the two of us work well together and have a good relationship. His response: "Why did you even apply to DO school?" Apparently back in his day my alma mater was sending letters to prospective med students inviting them to come there to study medicine, which gave him the impression that no one wanted to go there and they were desperate for students. Of course it's different now; our school has a good reputation for primary care and is fairly well known so there's no shortage of applicants. My partner then went on to express his astonishment that one of our favorite cardiologists (the only other DO in the hospital that I know of) matched into cardiology and became successful, as though DOs were only meant to do primary care and nothing else. His attitude reminded me exactly of my dad, who tried to convince me eight years ago to give up my spot at TCOM and reapply for MD schools because he didn't want me to be a DO. He'd heard from a MD neurologist that DOs had no respect in the medical profession and that people would always look down on them, and he didn't want that for me. Apparently when I made my rank list, he didn't think I'd actually match at a DO school so he didn't say a word, and he was very unsupportive when I told him I intended to keep my spot. Nasty words were hurled and we had a huge falling out afterwards; I had to escape to Taiwan for the summer to get away before I could speak to him in a civil manner again. I even recall looking at apartment brochures because there was no way I was going to move back home (even though school was 20 min away), but my mom talked me into it by promising me lots of privacy. Of course, this happened a long time ago and my parents couldn't be more proud of me now, but I can never forget the hell they put me through following Match Day, just because they wanted me to be an MD and not a DO.

The conversation I had with my partner, however, dragged up all those unpleasant memories again, and now I'm pissed and angry at him. Why should I have to justify why I was not an MD? Why was he asking me why I even applied to DO school in the first place, eight years after the fact? Back when I was debating whether to keep my spot or reapply the following year, an adviser at UT asked me this question when I told her my dilemma: "Do you want to be a MD, or do you want to be a physician?" The answer was obvious: I wanted to be a physician. And now that I've become what I set out to be eight years ago, I had hoped that my being a DO would not make a difference in how people saw me. And now it seems my own father was right all along. I just wish my partner would have kept it to himself and not thrown it in my face.

Fortunately, most of the people at work don't seem to care about the initials following my name, and if someone does bring it up, I dare them to say I'm a horrible doctor. Because I know that I'm good at my job, and that's what matters at the end of the day.

Being Prepared

After the bombing at the Boston Marathon on 4/15/13, plus the explosion at West and the ricin envelopes in DC, it's become more obvious than ever that no place is truly safe. At lunch yesterday I asked one of the emergency medicine docs if Austin was prepared for mass casualties (it's no longer far-fetched to think that someone may drop a bomb in the middle of SXSW someday), and he said yes. Apparently they run mass casualty drills once a year, and he recalled that when Hurricane Katrina hit, many patients from coastal hospitals were evacuated to Austin. I forget how many people he was able to triage in ___ hours, but it was done. He also commented that if anyone really wanted to do serious damage to Austin, then the football stadium at UT on any home game day would a prime target. Thousands of defenseless people in one spot, they'd be sitting ducks. Whereas at SXSW, everyone was all spread out. And of course UT is always a target; wasn't there already a shooting there in the 60s?

There are many runners at my hospital (one of my partners ran the Boston marathon years ago), so the bombings have been a hot topic here. I know a guy who is a surgery resident at one of Harvard's teaching hospitals, and he commented that he's been treating some of the victims from the bombing. I don't dare ask for details, but I imagine it must be hard being on the front lines, seeing the damage the bombs caused to these patients, trying to fix them up. What can an internist do in such a situation? I once admitted a patient for chest pain after her house caught on fire and her husband died in the fire (back in Philly), but that seems tame compared to what's going on now.

I certainly hope that I'll never have to encounter an event with mass casualties in my lifetime, but if I do, I would be out there helping others, just as we were taught (and called) to do. It's our duty as physicians.

The Weekend From Hell

Anyone who follows me on Facebook knows that I'm not the type of person who posts every day. This weekend was the exception. After returning home from 2 weeks of traveling in Sapporo, Bali, and Seoul, I was assigned "pit boss" duty, meaning that I take calls from the ED from 6am-12pm and distribute admissions among my partners. It also meant that on Monday morning I had to redivide our ENTIRE weekend census in order to even out everyone's census (since the total number of hospitalists rose from 8 on the weekend to 12 on the weekday). That was my first time "making the list" and it took me a good 2-3 hours (got to the hospital at 4:45 am, didn't finalize the list until after 7 am), but in the end I was satisfied with my work. Some of my partners have done a crappy job of dividing the list (where half of my patients from the previous week went to other people), but most of us who are off for the weekend want our old patients from the previous week back. I, of course, had a brand new census of people whom I'd never met before, but fortunately the average census was 14-15 people. I even took an extra  admission on Monday because I had room to spare (my "desired" census is 15 people/day) Stupid me, I thought being the pit boss meant I had to physically be in the hospital by 6 am (not true), and when one of my partners finally told me on a Thursday morning, I thought, "Oh, then on Friday I'll come in at 7:00." Big mistake.

Normally our group has a rule that there has to be ten hospitalists rounding on any given day so as to not overwhelm anybody. On Thursday there were 11 hospitalists; two were "charity" helpers (one was from another hospital, another should be post-night float but chose to work to earn extra money) and deserved to be off. The other, one of the senior partners, gave no notice except for a note on the board: "Off 3/1, back 3/2." Incidentally, the census at the hospital exploded to maximum capacity. So we went from 11 hospitalists to only 8 hospitalists (which is the number that typically works on weekends), and our individual census rose ridiculously high. I had left the hospital on Thursday with 13 patients; on Friday I had 22.

Some of the remaining partners were pissed, and rightfully so; one had only 11 patients left on Thursday, and she'd made a doctor's appointment for the afternoon. Another had just worked 2 straight weekends and was hoping for a easy Friday. Never mind that I was on call at 5 pm. The lowest census anyone had was 22. This was, essentially, a 3-day weekend type of census. It took me until 7 pm to see my inpatients and 1 consult, and then I got 7 admissions from the ED. In my six months here the hospital had never been so busy before, even during Christmas. The ED was holding 12+ admissions in their rooms because there were no more inpatient beds available; there were even stretchers in the halls, which almost never happens. I didn't see my last new admission until 11 pm; by that time I was pooped. Most people try to dictate their H&Ps while they're in the hospital, but I was so tired and sick of work I went home, showered, and then dictated from home. Then did my billing for the day. I didn't go to bed until 2 am. That day I saw 30 patients.

I need at least 4 hrs of sleep to function, so I woke up at 6, drank coffee to stay awake (which was against my better judgement; coffee in the morning makes me ill), and rolled into work around 7 am. Because I was tired, I wasn't able to keep up my usual pace, and by noon I'd only seen 11 of my 27 patients (including one new admission, which fortunately for me was straightforward syncope.) Of course, of those 10 I'd discharged a few, and discharges always slow me down. As expected the coffee gave me an upset stomach, so I was pretty much in misery the entire day. I didn't see my last patients until 7:30-8:00pm, just in time to hear one of my patients complain that he hadn't seen me all day. Total census that day: 28 patients. I discharged 7 and got my census down to 21.

Fortunately the admissions slowed down so that I only got 1 new admission overnight. I felt much more refreshed after getting 6 hours of sleep (rather than 4), so I was a bit faster. By noon I'd seen 13 patients and discharged 4. The call was not bad either; only 3 new patients. The problem was that a lot more patient families were visiting on the weekends, so I had to take time to speak with them (which sidetracked me), so I didn't see my last admission until around 8pm (again). I discharged another 7 patients and got my census down to 18. When I got home, I calculated that in the past 3 days, I'd worked 44 hours, examined 83 patients, and never saw the sun except from inside the hospital. Wow.

Residency nowadays cannot prepare future hospitalists for this kind of work. Not with patient caps of 14-16 and duty hour rules where an intern cannot work longer than 16 hours at a time. Now I understand why my pod leader looked concerned when I told her on my interview day that I never saw more than 14 patients on any given day; she was probably afraid I wouldn't be able to handle the workload here. I think she took quite a leap of faith in deciding to hire me, and I'm glad to say I made sure she didn't regret her decision. I heard her tell another interviewee that she thought I'd have trouble because I was "green" (complete rookie with no real life experience), but that I learned very fast and was doing pretty well. My other partners, too, have told me I'm doing a pretty good job, and one of the cardiologists told me that they missed me while I was on vacation ;). "You're a workhorse," he'd said. Guess that means I contribute to the group =)

Fortunately this month I'm based at a nearby rehabilitation hospital, which promises to be easier. Hope so.

Crazy people

Some of the patients on my census (and their families) are completely nuts. I was off last weekend, and my partner who covered my patients was more than happy to give them back to me. For all the good that I feel I do in taking care of patients who truly need medical care, then there are others who abuse the system.

One of these is a woman admitted for COPD who cannot stop smoking, refuses to get out of bed to sit in a chair ("I sat in a chair for 2 hours yesterday and then I got tired!), and eats like a pig. Never mind that she's diabetic; she calls the nutrition people frequently to order snacks, and is afraid to move for fear of coughing and being short of breath. She also engages in "extracurricular activities" that I have fortunately never witnessed, namely phone sex with her boyfriend. Apparently therapists have left her room because they were uncomfortable being in the room with her when she was going at it on the phone, and she hits on male nurses and doctors shamelessly, at times requesting to be bathed or cleaned by the male nurses. I'm hoping to send her home soon because all she does is eat and sleep, and she can do that at home.

10 days ago I admitted a 560 lb guy for cellulitis (had failed outpt therapy) and put him on IV antibiotics. Within days, he complained that his abdomen was feeling more "full" and he was having trouble breathing. Abdominal ultrasounds and CXR were wasted on this behemoth due to his habitus, and he got angry that we didn't have a CT that would fit him and demanded to be transferred to the county hospital where he thought they had a CT that would fit him (not anymore). He had to wait over the weekend to go to another hospital just for the CT, and during that weekend, he drove my partner nuts claiming that he couldn't breathe, he was going to code any minute, and that we needed to "fix" him. My partner created a new monster by putting him on IV lasix for diuresis (he also had lymphedema), and once he started peeing all that excess fluid out, he became happy with this method of weight loss and demanded that the Lasix be increased to q6. At one point he peed out 10L in one day, but it didn't help that he also drank 5L of sodas and water. He then claimed he couldn't walk due to his excess weight and demanded a scooter. We later confirmed he had borderline personality, but it was riduculous. He was convinced that he had CHF despite a negative echo and normal BNP, and he kept demanding to see a specialist. I flat out told him no. Finally, it took me, the case manager, the RN, and the floor supervisor to go to his room to confront him and say that there was absolutely NO indication for him to be in the hospital and that he was being discharged that same day. He agreed, but threatened to return if the PO lasix didn't get his fluid down as fast as the IV lasix did. When I dictated my H&P, I listed examples of his behavior and said that he should not be admitted unless it was a true emergency. After confronting him, I realized I'd developed quite a backbone since I dealt with my drug seeker about 2 months ago. I've grown up =)

Another woman has an extremely controlling family consisting of 9 children, each with different opinions. They live in the north part of the city, but in the past few months keep changing hospitals because they were "not happy" with the care they were receiving. Honestly, the problem is not the hospital but the family. The last hospital had discharged the patient to hospice for multiple medical problems including CHF and CVA; when she had a CHF flare, they refused to take her back to the previous hospital and came to mine to start anew. The family members were very demanding; they wanted her to go to one particular acute rehab despite the fact that she'd already used up her rehab days and Medicare wouldn't pay for the rest. One day the patient told me she wanted to go home with hospice; 5 minutes later, her daughter (and MPOA) talked her out of it and then told me, "Mom wants rehab." It seemed strange that her children keeping telling me how clear-minded the patient was and how she can make her own decisions, and yet when she wants to go home, her children put their foot down. When I asked the patient where she wanted to go, she said rehab. They again demanded a particular rehab, and the MPOA seemed okay with us referring her to a rehab center up north. Then today, one of the sons (whom I'd never met) called the CEO of the hospital claiming that the patient had been "manhandled" and accused our techs of physical abuse, even mentioning names of senators in order to get her to that particular rehab. This was AFTER the MPOA decided on another rehab. Don't these siblings talk to each other? It's disgusting how manipulative they are. One thing I have to do tomorrow is tell them that the patient is going to be discharged either home or to a different rehab and that they need to make a decision, pronto. After dealing with the lard-ass in the previous paragraph, I feel almost ready to confront any difficult patient or family member who's taking advantage of our system.

*sigh* Weekend can't come soon enough. These people drive me nuts.

Watching Life Slip Away

Shortly before Christmas I got a patient in the ED who had undergone PEA arrest but responded after 1 round of CPR and 1 dose of epi. His cardiac enzymes were negative and his EKG was ok, so when his wife asked what caused the PEA, I said it was most likely PE since he had a history of Protein C/S deficiency and wasn't therapeutic on coumadin. Later, the pulmonlogist called me up and said that the PEA was most certainly not caused by a PE. "If he had a PE, he wouldn't have come back after just one round of CPR and epi," he said. "People with massive PEs don't make it."

Last Friday I admitted a 48-year-old woman with metastatic breast cancer who came from her oncologist's office for dehydration and intractable back pain. Apparently she was in her normal state of health (driving her daughters to school, walking around fine) until 1 week ago, when she caught a cold and suddenly became weaker and had some witnessed syncopal episodes at home. Her CXR was clear, and her lumbar x-rays confirmed widespread metastatic disease. She asked me what the plan was now, and I said she'd probably need to talk to her oncologist to discuss goals of care. Before I left her room, I noticed that she looked slightly winded, but when I asked her about it she said her breathing was fine. Even still, I ordered a chest x-ray for the morning to see whether she had developed pneumonia.

Yesterday (Sunday), the on-call oncologist paged me to say he'd just seen my patient, and she "didn't look good." I immediately ran downstairs to her room, and she looked horrible. Her skin was pale, her hands were cold, and though she was able to follow commands, her speech had become terribly slurred. "What's wrong?" I asked, and she said, "Can't...breathe." Her X-ray that morning had been clear, so I quickly left the room to order a stat CTA chest. "She needs to go to the ICU," the nurse said, and I agreed; with a clear CXR and her history of breast cancer, she likely had a PE. I went back to her room after the orders were in, and I was immediately horrified by how much worse she looked. Her eyes looked blank, and suddenly, right in front of me, she stopped breathing. Her SpO2 rapidly dropped from the 80s to the 70s in seconds, and I immediately grabbed her wrist to feel for a pulse. Nothing. "Should I call rapid response or a [Code Blue]?" asked the nurse. I told her to call a code.

The woman had become unresponsive, and was only taking breaths every 8-10 seconds. Once she was hooked to the monitor, we saw her HR fall to the 40s and then asystole. By then CPR had started and the ED attending arrived to intubate her. Critical labs showed a K of 7.8 (it was 5 earlier that morning) and bicarb of 10, pH < 7. We regained a pulse and made arrangements to transfer her to the ICU. The ED attending and I stepped outside the room to write our notes when suddenly the Code was announced overhead again. My patient had once again lost her pulse, and another round of CPR, epi, atropine, and bicarb was given before she was stabilized enough to transfer to ICU. Fortunately during this time her mother called the nurse's station and was told what was happening, and she immediately drove toward the hospital.

I wish I could say my patient got better, but not long after she arrived at the ICU, she lost her pulse again and CPR resumed. The on-call cardiologist poked his head into the room to see what was happening (one of my partners saw me and thought yet another of my patients had coded), and when I explained the situation, he said I could pace her, but unless I fixed the underlying cause (presumed PE), she would continue to deteriorate. There was no end to this at all. Fortunately her mother arrived at the ICU, and the nurses encouraged me to bring her to the bedside to let her see what was happening. By that time the patient was stable again, and the mother said that if it was just her, she'd want to withdraw care, but that decision would have to be made by her 20-year-old son. I spoke to her son by phone and explained the situation, asking what his mother would want in this situation. "We talked about it a little, but never really made a decision," he said. I then encouraged him to come to the hospital as soon as possible. ("Drive safe," his grandmother said.)

I had taken the mother to the pre-op room to talk, but when we arrived back at the patient's room, she had lost her pulse a fourth time and CPR was resuming again. "Is she getting oxygen to the brain?" her mother asked. "How long has this been going on?" When I told her this was the fourth time she'd dropped her pulse in one hour, she was shocked. "Oh no," she murmured. "She wouldn't want this." She immediately called her grandson to let him know what was happening, and he said he needed to talk it over with another brother. By that time my patient was hooked to a pacer and maxed out on Levophed, Dopamine and Epi, yet her BP was only 55/32. This was a losing battle, and I think everyone was silently hoping that someone would make the call to stop the code. And that someone had to be me.

The patient's son called back, and after listening for a few seconds, her mother nodded and said, "I want you to tell the doctor what you've told me" and handed me the phone.

"My brother and I talked it over, and we know that my mom did not want to be a vegetable. She wouldn't want to be hooked up to life support."

"Okay. Right now, there are machines breathing for her and keeping her heart beating. Are you saying that you want us to stop everything we're doing?"

"Yes."

"Thank you," I said. Beside me, the mother nodded as I handed her the phone, then turned to the nurses and techs in the room and said the words everyone's been waiting to hear: "Stop everything."

The pacer and pressors were turned off, and almost immediately both HR and BP fell to zero. The patient's mother approached her and whispered, "I don't know if you can hear me, but I love you so much." That almost brought tears to my eyes. Time of death was called at 13:02, and I asked RT to extubate her before her son arrived. I felt horrible for the rest of the day and wondered what I could have done differently. A PE had not been on my differential when she arrived in the ED with generalized weakness, anorexia, and intractable back pain. But even then, I couldn't have given her anticoagulation because there was a questionable subdural hematoma on her CT head. It was a near hopeless situation. Maybe if I had more experience, I could have anticipated this earlier, but now it's too late.

We will never know what happened, but it's most likely she died from a massive PE. When I talked about this with the pulmonologist who attended the code with me, I remembered what the other pulmonologist had said: "People with massive PEs don't make it." Now I know what he meant, and this is yet another in a growing list of experiences that I will take to heart so that next time, I don't make the same mistake again.